Surgical management of presacral bleeding

Abstract

INTRODUCTION Presacral venous bleeding is an uncommon but potentially life threatening complication of rectal surgery. During the posterior rectal dissection, it is recommended to proceed into the plane between the fascia propria of the rectum and the presacral fascia. Incorrect mobilisation of the rectum outside the Waldeyer's fascia can tear out the lower presacral venous plexus or the sacral basivertebral veins, causing what may prove to be uncontrollable bleeding. METHODS A systematic search of the MEDLINE ® and Embase™ databases was performed to obtain primary data published in the period between 1 January 1960 and 31 July 2013. Each article describing variables such as incidence of presacral venous bleeding, surgical approach, number of cases treated and success rate was included in the analysis. RESULTS A number of creative solutions have been described that attempt to provide good tamponade of the presacral haemorrhage, eliminating the need for second operation. However, few cases are reported in the literature. CONCLUSIONS As conventional haemostatic measures often fail to control this type of haemorrhage, several alternative methods to control bleeding definitively have been described. We propose a practical comprehensive classification of the available techniques for the management of presacral bleeding.

Efficacy of rectus muscle fragment welding in the control of presacral venous bleeding

“…The failure of this method, development of presacral haematoma or chronic pain, detachment of the thumbtack, migration and per‐anal extrusion of the thumbtack and non‐routine availability of equipment have given rise to a series of creative solutions. Celentano et al . reviewed those solutions that have been reported within the last 50 years, which include the use of a ProTack™ device (Covidien, Mansfield, MA, USA) to plug the bleeding area with a haemostatic sponge fixed to the sacrum with endoscopic helicoidal tackers, bone cement, bone wax, the use of a breast implant sizer, a saline bag, haemostatic agents, electrocoagulation on an omental fragment, bone pericardium grafts, rectus abdominis muscle sutures, the use of titanium staples attached to the sacrum of a spongy bone graft, argon beam coagulators, direct bipolar coagulation, circular suture ligation and spray electrocautery.…”

“…Numerous different procedures have been reported to treat this complication, including packing techniques, tacking techniques, topical haemostatic agents and direct or indirect electrocoagulation and sutures …”

Complications of laparoscopic rectal cancer surgery

“…PSVP is formed by the two lateral sacral veins and the middle sacral vein, anastomosing with the internal vertebral system through the basivertebral vessels emerging from the sacral foramina. It is localised underneath the presacral fascia, being easily lacerated, with high propensity to bleed [33] . Managing bleeding from the pre-sacral veins is challenging; conventional methods such as direct sutures often fail and may exacerbate bleeding.…”

“…A "second-look laparotomy" is required in 24-48 h to remove the packs, as leaving a large volume of foreign body in situ can increase the risk of pelvic sepsis [34] . Sterile thumbtacks could be used as an alternative, but they are ineffective in case of diffuse haemorrhage, and some authors report chronic pain and anastomotic fistulas related to their placement in the presacral space [33] . Other techniques have been suggested such as topical haemostatic agents [32] , direct or indirect coagulation with spray electrocautery, argon or bipolar coagulation.…”

New method of stopping bleeding from the presacral venous plexus during the rectal cancer operation: a case report

“…Традиционные методы гемостаза при повреждении вен крестцового сплетения, возникающем в 0,25-3,0 % случаев, -использование прошивания, электрокоагуляции, аргона, гемостатических материалов, сварка с фрагментом мышцы или сальника, применение баллона, кнопок и гвоздей различной конструкции, клипирование -несмотря на ранее проведенную перевязку внутренних подвздошных артерий, нередко Colorectal КОЛОПРОКТОЛОГИЯ 3' 2018 К л и н и ч е с к о е н а б л ю д е н и е малоэффективны [2][3][4][5][6][7][8][9][10][11][12][13][14]. В данной ситуации большинство хирургов нередко прибегают к тугой тампонаде данной зоны как к последнему эффективному способу.…”